S 0873APPLICANTTO FILL IN INFORMATION WITHIN RED LINES - USE BALL POINT PEN ONLY
CITY OF CUPERTINO BUILDING - ELEC`T'RICAL
BUILDING DIVISION APPLICATIONIPERMITPLUMBING - MECHANICAL
BUILDING PROJECT IDENTIFICATION
PRRMIT NO.
V
S 0873
BUILDING AD RPSS:
��
yy -
r �-h� RQ
SANITARY NO.
APPLICATION SUBMITTAL DAT[
TA
O ': 'SWMB: 11 PHONE:
���1...
CO ACI'O'SN EI LIC NO:
I.1.
NIC
CONTROhp
TT Ve�,Cg
F
CONTACTPHONE:
DU ILDIN : PFRMIT INFO
^
&V 1 M � I0 - 2 o/
IYGI/rJt V L�t7
❑ Consultant Fees Paid by Applicant (Initial)
BLDG I],F,CI' PLUMB MECH
Q=Z
WOO
�UF
6 U
FF Z W
b Q6.
Fs D m
Z 1n Z
OZ=O
F-�nF u]
C C C Q
hereby
O i U
F.�oc.0 N
¢
J
ad 00
d L c
XI
�..y
F-Z.Y
y6
SFO
W_ ce
LICFNSED CONTRACTOR'S DECLARATION
L herchy afern thin Ion ncen,m nndcr pt—Woes or chapter Y (cnnm:endng
with Section?000) of Division 3oflhe13-messand Pnsfosions Code.and my license is
in full forcevnd effect.
4ccnse Class Lich
Date Commaor
QTY. ELECTRIC PERMIT FEE
JOB DESCRIPTION
RESIDENTIAL:
❑SFDWL ❑ KITCHEN RIiMODEI.
❑ADDITION [I PLUMBING RE-PIPE
❑MULTI-UNIT El STRUCTURAL
MODIFICATION
❑INTIiRIOR ❑CHIMNEY REPAIR
IMPROVI?MEN'F [DSWIMMLNG POOLS
❑BATH RF.MODEIIRIiPA1R ❑DEMOLITION
❑ OTHER
PERMI I' ISSUANCE
APPLIANCES - RESIDENTIAL.
ARCIII'fF,CTS DECLARATION
1 nndcca:mJ my plans sM1ull be owJ as public records
PANI3LS
UP TO 211fInMI'S
Liccascd Pm1c,slnml
OWNER-BUILDER DECLARATION
I affirm thin I anm t exempt frothe Conlracmra Licarse Law for the
following reason. (Section 7031.5. Business and I'ntfesslons Calc: Any city or county
which mquircs a lxrmit inconstmet, alter. Improve, demolish, or repair any scram e
priotlI baltdoe, BO.,hemnf in Eagrait tofile a lipird nen
'hat he is licensed puroagard to the provisions ofilic C License an (Chapter
kammencingwith Sat m]nfXp ofDvsinn3ofthc Hu'nu: dl (..ons CORE (it
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Sectiun7031.5 by nny uPPlimnt lar a permit subjects the applicvmm a civil fagultyof
oat more than live hundred d.h.,s 55801.
F1 1. as owner ofthe property, or my ernpluyccs with wage' as tneirsnle compemation.
will do the wad. and the nmcwrc is nm in¢ndcJ nnHlircdlnr sale (Sec. ]1114, Itu>incss
vnd.Pudh,,slons Code: Me Contractor's License Law does not apply m ..,.all of
who builds Or improves thereon, and who does such work himsclr or though
201.](MAMPS
OVBR 10010 AMPS
SIGNS HLECTRICAL
SPECIAL CIRCUTIMISC.
TEMPMEFR OR IOLIi(NSI
COMMERCIAL :
EW BLDG/ADDITION [IDEMOLITION
NANT [I FOOD SFRVICit
OVF,h1ENT
IEX.
❑OTHER
POWER D17VICES
SWIMMING pOO1.li1,F.C1'RIC
PUTT.In'S-SWITCHES- PIKE 'URIiS
property
his own employees, providal That such impmremems arc not intended or uttered for
sale, If. however, the building or improvement is sold within one year ofcanpleuon.the
NBW RESIDEN'HAL ELECTR SQ FF
SQ.IT. FLOOR AREA
bISQ. FT.
toxner,omider will have the burden of proving that he did not haild or improve for par-
psre of vowne
y�
rPcife®
with licensed contractors, in
I. astweeoject property,nmewlusivnd
Profescon%
ecrtama the project (Sec ]w4. Puniness and ray who bui Code:l Dm Cs magern, Li-
e does J
ownerofprnpny whosedE
O�e`
QTY. PLUMBING PERMIT FEE
mLigs ror mant tabeContra
mucsfnatvpplymrm
was, �amracl. rarynen pnjeas wnnneano-actm(alra teal pannammtneeamaemr.
Liego, La,
E] el nm esempt mode, Sec. . B & P C for this reason
E8v5
Y
PERMIT ISSUANCE
AI;TF.R-DRAIN&VENT -WAI'L .A)
Owner 'Date
r' �IIfY ATION
WORKER'S COMPENSATION DECLARATION
BACK FLOW PROD FCT406
1 hereby affirm under Penally of perjury one of the following declarations:
❑ I have and will maintain aCeriGcateof Consenunseluinsure for Workers Compcn-
moan, as providad for by Section 3700 of the LgNor Calc, for the performance of the
✓` L.y
'TST'
YPE CONRUCT'ION
DRAINS- FLOOR, ROOP.ARCA. Ot(S3'OR113S
wod for which This lentil is issued.
PIXTIIRI3S - PCR (RAI'
El I h:ne and will maintain Warkers Compensaion Imurence, as reyuim l by Section
3]1X1al be Labrt Cede. for the perfatmanvor the work for which this permit is issued.
GAS -EA. SYSTEM-I INC. 4 OUTLETS
OCC, GROUP
AI'N
My Worker's ComPerattion Insurance wrier and Policy another are!
Cyder, Policy NO,:
GAS -EA. SYSTEM -OVER 4 (EA)
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCH
Obis section need not ON completed if the permit is for nuc hundred dollars is (0)
or less.)PLANCHECK
GRI?ASMNUUSTRL ST17 IN'FCRCCPOOR
BUILDING DIMS N PEfiN
GRL'ASL'I'RAY
FEF
SEWER-SANITARY-SI'ORh I
zZ
Icenify thatin the performance of the work Ltrwhlch this permit is issued, lshaft
not employ any person in any manner so as m Mcome subject to the Worker: Compen-
sotico Laws Of California. Date
Applicant 'LE
ENERGY FUE
GRADING F P
WATER HEATER WIVENT/ELECTR
.N.
a >
Q
7 Z
(,O
� Fthe
N(yricE'FO API'I.LCAN . IC afmt making Ibis Cenilicme nI Exemption, you should
heroine mhjea m the Workcrs Compcusgion provisions .1 the Lahr C Je, you must
forthwith corn ply with such provisions nr this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
forshich thi thatthereis odl Sr,.30 len Jing agencyfor the perfomtancc of
work fine which this permit is i-sued (Scc.3W], Civ. C.)
WATISR SYSTEMIFIORNI'LNG
WATER SERVICE
SOILS FE
PAID
Dote RccciplK
NFW RESIUF.Nf1Ah PLMB. SG Irf.
Lennon Name
Lcndcrs Address
I rectify aha 1 have mud this a,micmion:mJ ogle thin Ile above information in
correct. I agree to comply with all City and county onllnances and sera paws renting to
builiing commierion, and hereby authorize represenmtivesof this city loenterupanlhe
TOTAL:
RUILUINC FEL
W
Fd
EA
V Z
QTY. MECHANICAL PERMIT FEE
SEISMIC THE
ahnvo-mumtioned paopeny far Inspection purpatwY.
(We) agree to save. indemnif d late, handles, the Cil f Ci lino n uinsl
Y an D Y o prr g
PERMIT ISSUANCIi
ELECTRIC FRE Z
�EsLTER OR ADD TO MECH.
PLUMBING FFF
liabilities,judgments, roes and expenan which nny in nny way neem¢ against said City
in consequencepe
of the granting of This rmit.
AIR HANDLING ON] TOO 10.01X1 CFM)
MCCIIANICAL HE
APPLICANT UNDERSTANDS ANI) ILL COMPLY WITH ALL NON-POIN I
SOURC RF.0 t
t� r
AIR HANDLING UNITIOVGR 10,10,000gCMM)
it
CONSTRUCTED AX
esus4 Date
HAZARDOUS MATERIALS DISCLOSURE
EXHAUST HOOD OVIDUCT)
HOUSING MITIGATION
HEATING UNIT(TO 100,000 RTU)
Will the applicam or future Inildingoccupammore orhandle hazardous material
as dclined by Ibe Cmpenino Municipal Code. Chupo-r 9.12, and the Health and Safety
Code, Secdnn 25532(a)?
HEATING UNIT (OVER IOO.IKKI BTU)
E] Yes MNo
Will the applicant or ar ,ubuilding atccup:un use eyuiprnem nr devices which
mit nemalomx an mngminnng as defined by the Bay Areo Air Quality Mumgemenl
District]TOTAL
E] Yes NO
PAID
Date Reccipt M
VFN'FILATION FAN (SINGLE RESIDE
BOILER-COM(' (HIP OR IIIO.(IOII I1TU)
BOILER-COME'(OVFR I(X)OW) BTU)
AIR CONDITIONER
I have real the hnrafdnms ot am,1, re u under Chu Ter fi.95 0l the Cali-
ynimnsn p
ISSUANCE DATE
NEW RP_SIDENTIAL MFAII. SQ, FT,
human Health & Safe �- Scctinna 2550 $$33 unit ZM: I understand That the
1rullJing Ja'[ IzurmlWyh Ferny responsibility mnmify the atRup:mt
an be reaafliNfat, Rich n,w am. conneeafacenihcaa ar (xemeanet�.
_
ISSUED BY:
OFFICE